angie perrin lead nurse/clinical nurse specialist oxford...
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Angie PerrinLead Nurse/Clinical Nurse SpecialistOxford Radcliffe Hospitals NHS Trust
BackgroundBackground
• Late in 20Late in 20thth century saw revolutionary century saw revolutionary surgical advances within colorectal spheresurgical advances within colorectal sphere
• 1978 Parks & Nicholls modified internal 1978 Parks & Nicholls modified internal pouch, previously experimented by Ravitch pouch, previously experimented by Ravitch in 1947 on dogs!in 1947 on dogs!
• 1984 11984 1stst ileo-anal pouch formed in Oxford ileo-anal pouch formed in Oxford
Ileo-anal pouch developmentsNo stoma
No access to Clinical Nurse Specialist, stoma care
Lack of support generally
1991 – Kangaroo Club was borne
1993 - ia became Ileostomy Association and Internal Pouch support group
Ileo-anal pouch developmentsIleo-anal pouch developments
• Shape S, W or JShape S, W or J
• Staged approachStaged approach
• Ileostomy v No Ileostomy v No ileostomyileostomy
• Mucosectomy v No Mucosectomy v No mucosectomymucosectomy
• Hand-sewn or Hand-sewn or stapledstapled
The ileo-anal pouch procedure is now viewed as the operation of choice for those individuals with a diagnosis of Ulcerative Colitis and Familial Adenomatous Polyposis.
(Fazio 1998, Seidel, 2000)
Laparoscopic V open surgeryLaparoscopic V open surgery
Ileo-anal pouch developmentsIleo-anal pouch developments
Laparoscopic V Open surgery
Short term advantagesShort term advantages
Better cosmesis
Shorter length of stay Bemelman, 2003
Longer Term AdvantagesLonger Term Advantages
Less adhesions (mostly animal studies
Less incisional hernias
Oxford
Colorecta l
Lap-assisted pouch
first-stage colectomy
Oxford
Colorecta l
Lap-assisted pouch
second-stage proctectomy and pouch
Oxford
Colorecta l
Stage 1Stage 1
• Total Colectomy and formation of end Total Colectomy and formation of end ileostomyileostomy
“Quality of life is already satisfactory after CURE of the disease, irrespective of surgical procedure.”
Weinryb 1995
Considerations for patientConsiderations for patient• Age, SexAge, Sex• LifestyleLifestyle• Detailed understanding of both surgical Detailed understanding of both surgical
procedures, expected lifestyle post-surgeryprocedures, expected lifestyle post-surgery• Motivation for staged surgeryMotivation for staged surgery• Fertility and Fecundity issuesFertility and Fecundity issues• Body Image and SexualityBody Image and Sexuality• Quality of lifeQuality of life
Pre op assessment :Pre op assessment :
• Anorectal physiology Anorectal physiology studies.studies.
• Pre op counsel- Pre op counsel- advantages and advantages and disadvantages.disadvantages.
• Meet other pouch Meet other pouch owners.owners.
• Availability to support Availability to support groupgroup
• Age group Age group
• Good understandingGood understanding
• Good coping strategyGood coping strategy
• Family planning issues Family planning issues – –
Fertility/FecundityFertility/FecunditySperm savingSperm saving
Stage 2Stage 2
• Formation of J pouch and loop ileostomyFormation of J pouch and loop ileostomy
Stage 3Stage 3
• Closure of loop ileostomy = Functional Closure of loop ileostomy = Functional PouchPouch
Common concernsCommon concernsPeri-anal skin sorenessPouch LeakagePeri-anal itching
Frequency
Slight incontinenceDietary concernsGeneral anxietiesSexual function/Fertility & Fecundity
Ineffective emptying
Sore BottomSore Bottom
R e c t a l B u r n / I t c h P o u c h L e a k a g e
P e r i - a n a l s o r e n e s s
Good Anal Skin Care
Still sore Re-assess
Common concernsCommon concernsPeri-anal skin sorenessPouch LeakagePeri-anal itching
Ineffective emptying
Slight incontinenceDietary concernsGeneral anxietiesSexual function/Fertility & Fecundity
Frequency
Bad pouchBad pouch
Frequency• Tightening of anastomosis• Stricture• Habitual• Ineffective pouch emptying• Pelvic Floor Exercises • Using correct muscles/posture – pouch re- training• Use of Medena Catheter
DietDiet
50% individuals modify their diet
Not adequately discussed by Health Care Professionals
Attitudes towards food “ I eat late and do not follow any rules, I don’t do any of those things your supposed to do. I do what everyone else is doing. I have a drink, life’s too short!!
Lack of literature regarding diet
Information PrescriptionInformation PrescriptionSupport and lack of support from health care professionals
Value of support groups, chat rooms etc
Advocacy for fellow sufferers and “pouchies”
Lack of knowledge and understanding from health care professionals and others Eg. Insurance companies,
Lack of resources, inadequate literature
Difficult pouchDifficult pouch
•PouchitisPouchitis
•CuffitisCuffitis
• Irritable pouch syndromeIrritable pouch syndrome
PouchitisPouchitis
• Incidence of pouchitisIncidence of pouchitis• Clinical symptomsClinical symptoms• Clinical definitionClinical definition• Grading Acute/Chronic ScoreGrading Acute/Chronic Score• Chronic pouchitisChronic pouchitis• Use of titrating antibiotic dosageUse of titrating antibiotic dosage• AntibioticsAntibiotics• Probiotics VSL#3 Probiotics VSL#3 (Gionchetti, 2004)(Gionchetti, 2004)
• Anti TNF - InfliximabAnti TNF - Infliximab
CuffitisCuffitis
• Is a cause of pouch dysfunction after double stapled procedure.
• Defined as inflammation at the columnar cuff and is situated above the anal transition zone.
Irritable pouch syndromeIrritable pouch syndrome
• Clinical symptoms of pouchitis, but no cuffitis Clinical symptoms of pouchitis, but no cuffitis and pouchitis disease activity score <7 and pouchitis disease activity score <7
• Treated with variety antidiarrheal, anti-Treated with variety antidiarrheal, anti-depressant and anti-cholinergic medicationdepressant and anti-cholinergic medication
• Some responded well, others continue to suffer Some responded well, others continue to suffer with persisting symptomswith persisting symptoms
is said to be a condition resembling Irritable is said to be a condition resembling Irritable Bowel Syndrome Bowel Syndrome (Shen et al 2002)(Shen et al 2002)
The ileo-anal pouch procedure is now viewed as the operation of choice for those individuals with a diagnosis of Ulcerative Colitis and Familial Adenomatous Polyposis.
(Fazio 1998, Seidel, 2000)
Desouza 1995
“Functional results and quality of life were
excellent following ileo-anal pouch formation”
Angie PerrinLead Nurse/Clinical Nurse SpecialistOxford Radcliffe Hospitals NHS Trust